Provider Demographics
NPI:1558404863
Name:INGRAM, CONSTANCE
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 TAPPING REEVE VLG
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06759-3323
Mailing Address - Country:US
Mailing Address - Phone:860-459-6933
Mailing Address - Fax:410-861-6262
Practice Address - Street 1:906 BANTAM ROAD
Practice Address - Street 2:
Practice Address - City:BANTAM
Practice Address - State:CT
Practice Address - Zip Code:06750
Practice Address - Country:US
Practice Address - Phone:860-459-6933
Practice Address - Fax:410-861-6262
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0054381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical